The early 19th-century literary figure Thomas de Quincey was an opium user. “The subtle powers lodged in this mighty drug,” he enthused, “tranquilize all irritations of the nervous system … stimulate the capacities of enjoyment … sustain through twenty-four hours the else drooping animal energies … O just, subtle and all-conquering opium … Thou only givest these gifts to man; and thou hast the keys of Paradise.” A patient of mine in Vancouver’s infamous Downtown Eastside said it more plainly: “The reason I do drugs is so that I don’t feel the f***ing feelings I feel when I don’t do drugs.”

All drug addicts, even (or perhaps especially) the abject and marginalized street user, seek in their habit the same paradise de Quincey rhapsodized: a sense of comfort, vitality, and freedom from pain. It’s a doomed search that puts in peril their health, societal position, dignity, and freedom. “I’m not afraid of death,” another patient told me. “I’m more afraid of life.” What kind of despair could lead someone to value short-term pain relief over life itself? And what might be the source of such despair?

Not Choice or Genes

In North America, two assumptions inform social attitudes toward addiction. First is the notion that addiction is a result of individual choice, of personal failure, a view that underlies the legal approach toward substance dependence. If the behavior is a matter of choice, then it makes sense to punish or deter it by means of legal sanctions, including incarceration for mere possession. The second perspective is the medical model that sees addiction as an inherited disease of the brain. This view at least has the virtue of not blaming the afflicted person—after all, people cannot help what genes they inherit—and it also offers the possibility of compassionate treatment.

What kind of despair could lead someone to value short-term pain relief over life itself? And what might be the source of such despair?

What the choice and heredity hypo­theses share in common is that they take society off the hook. Neither compels us to consider how a person’s experience and social position contribute to a predisposition for addiction. If oppressed or marginalized populations suffer a disproportionate share of addiction’s burden—as they do, here and elsewhere—it must be due to their faulty decision-making or to their flawed genes. The heredity and choice-based models also spare us, conveniently, from looking at how our social environment supports, or does not support, the parents of young children, and at how social attitudes and policies burden, stress, and exclude certain segments of the population and thereby increase their propensity for addiction.

Another, starker view emerges when we listen to the life histories of substance abusers and look at the ample research data.

Addictions always originate in unhappiness, even if hidden. They are emotional anesthetics; they numb pain. The first question—always—is not “Why the addiction?” but “Why the pain?” The answer was summed up with crude eloquence, scrawled on the wall of my patient Anna’s room: “Any place I went to, I wasn’t wanted. And that bites large.”

“A Warm, Soft Hug”

For 12 years I was staff physician at the Portland Hotel, a nonprofit, harm-reduction facility in the Downtown Eastside, an area with an addict population of 3,000 to 5,000. Most of the Portland’s clients are addicted to cocaine, crystal meth, alcohol, opiates like heroin, or tranquilizers—or to any combination of these things.

“The first time I did heroin,” one of my patients, a 27-year-old sex-trade worker, once told me, “it felt like a warm, soft hug.” In a phrase, she summed up the deep psychological and chemical cravings that make some people vulnerable to substance dependence.

Contrary to popular myth, no drug is inherently addictive. Only a small percentage of people who try alcohol or cocaine or even crystal meth go on to addictive use. What makes those people vulnerable? According to current brain research and developmental psychology, chemical and emotional vulnerability are the products not of genetic programming but of life experience. Most of the human brain’s growth occurs after birth, and so physical and emotional interactions determine much of our neurological development—which brain areas will develop and how well, which patterns will be encoded, and so on. As such, each brain’s circuitry and chemistry reflect individual life experiences as much as inherited tendencies.

Makeshift needle exchange in Vancouver, B.C., which has the highest heroin death rate in North America.

Photo by D.M. Gillis.

Drugs affect the brain by binding to receptors on nerve cells. Opiates work on our built-in receptors for endorphins—the body’s own, natural opiate-like substances that participate in many functions, including regulation of pain and mood. Similarly, tranquilizers of the benzodiazepine class, such as Valium, exert their effect at the brain’s natural benzodiazepine receptors. Other brain chemicals, including dopamine and serotonin, affect such diverse functions as mood, incentive- and reward-seeking behavior, and self-regulation. These, too, bind to specific, specialized receptors on neurons.

But the number of receptors and level of brain chemicals are not set at birth. Infant rats who get less grooming from their mothers end up with fewer natural “benzo” receptors in the part of the brain that controls anxiety. Brains of infant monkeys separated from their mothers for only a few days are measurably deficient in dopamine.

It is the same with human beings. Endorphins are released in the infant’s brain when there are warm, non-stressed, calm interactions with the parenting figures. Endorphins, in turn, promote the growth of receptors and nerve cells, and the discharge of other important brain chemicals. The fewer endorphin-enhancing experiences in infancy and early childhood, the greater the need for external sources. Hence, a greater vulnerability to addictions.

Chronicles of Pain

What sets skid row addicts apart is the extreme degree of stress they had to endure early in life. Almost all women now inhabiting “Canada’s addiction capital”—as the Downtown Eastside of Vancouver has been called—suffered sexual assaults in childhood, as did many of the males. Childhood memories of serial abandonment or severe physical and psychological abuse are common. My patients’ histories are chronicles of pain upon pain.

Feeling alone, the sense that there has never been anyone with whom to share their deepest emotions, is universal among drug addicts.

Carl, a 36-year-old Native man, was banished from one foster home after another, had dishwashing liquid poured down his throat for using foul language at age 5, and was tied to a chair in a dark room to control his hyperactivity. When angry at himself he gouges his foot with a knife as punishment.

But what of families where there was not abuse, but love; where parents did their best to provide their children with a secure, nurturing home? After all, addictions also arise in such families. The unseen factor here is the stress the parents themselves lived under, even if they did not recognize it. That stress could come from relationship problems or from outside circumstances such as economic pressure or political disruption.

The most frequent source of hidden stress is the parents’ own childhood histories that saddle them with emotional baggage they are not conscious of. What we are not aware of in ourselves, we pass on to our children. Stressed, anxious, or depressed parents have great difficulty initiating enough of those emotionally rewarding, endorphin-liberating interactions with their children. Later in life such children may experience a hit of heroin as the “warm, soft hug” my patient described: What they didn’t get enough of before, they can now give themselves through a needle.

Unconditional Love

The U.S.-based Adverse Childhood Experiences studies have demonstrated beyond doubt that childhood stresses, including factors such as abuse, addiction in the family, a rancorous divorce, and so on, provide the template for addictions later in life. It doesn’t follow, of course, that all addicts were abused or that all abused children become addicts, but the correlations are inescapable.

If we look closely, we’ll see that addictive patterns characterize the behaviors of many members of society, including high-functioning and respectable citizens. As a workaholic doctor, I’ve had my own non-substance addictions to feverish professional activity and also to shopping. In my case, I can trace that back to emotional losses I suffered as a ­Jewish infant in Nazi-occupied Hungary during the last years of World War II. My children, in turn, were subjected to the stresses of a family headed by a workaholic father who was physically present but emotionally absent.

Feeling alone, the sense that there has never been anyone with whom to share their deepest emotions, is universal among drug addicts. That is what Anna had lamented on her wall. No matter how much love a parent has, the child does not experience being wanted unless he or she is made absolutely safe to express exactly how unhappy, or angry, or hate-filled he or she may at times feel. The sense of unconditional love, of being fully accepted even when most ornery, is what no addict ever experienced in childhood­—not because the parents did not have it to give, but simply because they were too stressed, or overworked, or beset by their own demons, or simply did not know how to transmit it to the child.

Addicts rarely make the connection between troubled childhood experiences and self-harming habits. They blame themselves—and that is the greatest wound of all, being cut off from their natural self-compassion. “I was hit a lot,” 40-year-old Wayne told me, “but I asked for it. Then I made some stupid decisions.” And would he hit a child, no matter how much that child “asked for it,” or blame that child for “stupid decisions”? “I don’t want to talk about that crap,” said this tough man, who has worked on oil rigs and construction sites and served 15 years in jail for robbery. He looked away and wiped a tear from his eyes.